American politics

Organ sales

Paying to live

ALEXANDER BERGER is a saint. Tomorrow Mr Berger plans to donate one of his kidneys to someone he's never met. He's a bit nervous, but he believes in what he's doing.

Most people think this sounds like an over-the-top personal sacrifice. But the procedure is safe and relatively painless. I will spend three days in the hospital and return to work within a month. I am 21, but even for someone decades older, the risk of death during surgery is about 1 in 3,000. My remaining kidney will grow to take up the slack of the one that has been removed, so I'll be able do everything I can do now. And I'll have given someone, on average, 10 more years of life, years free of the painful and debilitating burden of dialysis.

Mr Berger would be angry that I called him a saint. He thinks "deifying donors only serves to make not donating seem normal." He'd rather such donations be seen as "one of the many ways a reasonably altruistic person can help others."

But that's not how organ donation is viewed in America, which is why the number of donations (whether from living or deceased donors) does not keep up with demand. There is a growing waiting list for kidneys, for example. "More than 34,000 people joined the waiting list in 2010; fewer than 17,000 received one," notes Mr Berger. "Thousands of people die waiting each year."

So what can be done, apart from donating your own organs? Mr Berger suggests lifting the ban on organ sales, a solution that assaults the moral senses of many Americans. In the comments on Mr Berger's piece, a number of people praise the young man's decision but find his suggestion unethical. A market for organs would rely on vulnerable people desperate to get out of their economic straits, they argue. "Would there emerge from lower and working classes a permanent caste of people willing to be kidney dispensaries for the ill who are better off financially—or have superior health insurance coverage? Likely so, and to the detriment of our collective human dignity," says one commenter.

It is odd that we consider this ethical dilemma when presented with the idea of organ sales, yet largely ignore it when considering similar transactions. What is so different about paying a young man for his kidney and paying him to go off to war or perform any number of jobs that harm his health? All rely, to some extent, on the desperation of the lower-class. In the mid-2000s, as the Iraq war reached its bloody peak, the Pentagon recruited heavily in economically depressed areas. And black-lunged coal miners are rarely the sons of millionaires. Yet there is something icky about organ sales that seems to set it apart.

Unfortunately, the public's aversion to organ sales hasn't stopped them from taking place. There is already a caste of people willing to be kidney dispensaries for the ill and at present they navigate a horrific black market in order to sell their goods. In these shady deals they are often manipulated and misled and the risks to their health are much greater than they need to be. The transaction is nearly as risky on the other end, where recipients practicing "transplant tourism" may go home with an organ that is diseased or unsuitable. Would it not be better for everyone to regulate this market and clear the waiting lists for organ transplants?

There are also strong utilitarian arguments for allowing the regulated sale of certain organs. With kidneys, for example, donors like Mr Berger see only the slightest increase in their risk of dying from kidney disease. And their altruism is likely to lead to more than a decade of improved and prolonged life for the recipient. Donations are also cost-effective. As we noted in a previous report on the topic, "the cost of one kidney operation and a lifetime's supply of anti-rejection drugs equals that of three years' dialysis." And we have proof that such systems do fill the needs of the ill. Iran adopted a system of paying kidney donors in 1988 and within 11 years it became the only country in the world to clear its waiting list for transplants.

If you are unconvinced by the regulated-market solution to the world's organ-shortage problem there are still other ways forward. For example, payment could be restricted to families of deceased donors. Or America could move from an opt-in system for organ donations, whereby people must agree to make such gifts, to an opt-out system, under which consent of the deceased is presumed. Such systems (commonly found in Europe) do not always lead to higher donations, but there is a good chance that it would in America, where an advanced transplant infrastructure is already in place. For individuals looking to encourage donations, there is the option of joining a group like LifeSharers. That organisation assures that your organs go first to people who have agreed to donate their own organs upon death. And, of course, the easiest thing one can do to help those in need is to simply register as an organ donor.

This is a bit personal for me. Yesterday I got the news that someone I knew had just died. She made it to the top of the list for receiving a donated liver, but died before one became available.

Now, a liver is different than a kidney. You only have one, so you can't donate before you die.

To me, the case for donation on death is pretty clear. I am not my body. If I'm dead, then whatever I am (I leave the theological debate for a different time), I'm gone. I don't need the body parts. So take them with my blessing, because I don't need them any more.

Just because donations are technically free doesn't mean they actually are. A shortage in the organ market results in higher prices like in any other market involving supply and demand. The difference is that the price is paid differently from normal, usually involving hiring lawyers to make the case that you need a free organ more than others. Making a legal market for organs would lower costs by reducing the shortages of organs.

As always seems to be the case, well meaning people are unintentionally making things worse.

As the death toll from the organ shortage mounts, public opinion will eventually support organ sales in the United States. Changes in public policy will then follow.

In the mean time, there is an already-legal way to put a big dent in the organ shortage -- allocate donated organs first to people who have agreed to donate their own organs when they die. UNOS, which manages the national organ allocation system, has the power to make this simple policy change. No legislative action is required.

Americans who want to donate their organs to other registered organ donors don't have to wait for UNOS to act. They can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Everyone can offer to donate their organs when they die, no matter what their medical condition or history is. So non-donors should go to the back of the waiting list as long as there is a shortage of organs.

Thank you for being willing to write a post in support of organ sales. Allowing informed consenting adults to sell their kidneys would save thousands of lives while reducing harm to donors, who could now receive proper medical care in an official hospital, instead of dubious operations in a back room.

I have always thought the law against selling organs is extraordinarily irrational. Mr Berger, in this article, has decided to give away his kidney out of no reason but altruism, and most people would be unwilling to object to that. If Mr Berger had instead decided that he would be willing to trade his kidney for a few thousand dollars, would he be more or less rational? Could you describe him as "exploited" and would he be more or less exploited than when he chooses to give his kidney away for free?

Suppose that Mr Berger had some severe illness and no health insurance. As the law stands, he could not sell his kidney to raise money to save his own life. How does that improve his human dignity? And how does the law improve the dignity of the tens of thousands of sick people who are desperately in need of a kidney and willing to pay a fair price for one?

Historically, people have sold all sorts of things of themselves -- hair and teeth, for example. Some people sell their bodies for use in sex, and there is a vocal liberal community that advocates making that legal everywhere too. Eventually, I guess we will become jaded enough that selling organs to the highest bidder will seem perfectly normal.

I would just caution advocates of such a regime -- the day you need a kidney or other organ, you should pray that someone else with greater resources (and in perhaps less dire need) doesn't outbid you for it.

I struggle to conjure up some solid reason why selling organs or organ rights should not be legal. All I can come up with is that most people react to organ sales with a visceral "ewww!" and stop listening, or at least try to rationalize a ban with the fig leaf 'dignity' argument. They then change the channel and keep pretending that no one they know, and certainly not them, will ever need an organ transplant. Denial is a comforting place to snooze, so I am pessimistic that the ranting of the rational will ever nudge this 'debate'.

So perhaps the best recourse against irrationality is not reason. It is fear. Somehow we must get every good American to ask themselves what public policy they would want if they just heard their doctor say "without a new liver, in two or three months you (or your loved one) will be dead". Unfortunately, America will never ask itself this question unless it is cleverly inserted into a sitcom or something else to which we actually pay attention. Donald Trump or Rush Limbaugh will not touch it, so we must place our hopes with, ahem, Hollywood. God help us all.

R.M., the more I think about this, the more I think you picked an exceptional case - kidneys. You get two, and you only need one. But what about hearts? You only get one; the only "market" is in dead people. Livers? Ditto. Retinas? You get two... but you really want them both. You're not going to have a reasonable market in people selling off one retina. Even more so, you're not going to have a reasonable market in hearts or livers.

The only other thing that I can think of that people donate that somewhat compares to kidneys is blood.

I know economists love organ markets but financial incentives to sacrifice vital organs seems unethical to me. You might say that it's the same as paying someone to work in a coal mine. It might be the same to a consequentialist but not to a moralist who believes that intended purposes matter. Peabody doesn't pay its employees for their lungs. It pays to extract coal, a morally neutral act, with black lungs being an unintended consequence. An organ market would pay people to sacrifice their bodies. Opt-out with some additional safeguards seems like a good idea to me.

I think there is an important aspect of creating this market that was not discussed in the article. Creating a market will help create and stabilize a price for organs. Once the legal market is created and a price set, investment will follow. A lab researching methods of organ creation will then look like a very good opportunity as there is an existing market for the eventual product. Even with the present underinvesting science is coming close (and achieving succes for some organs albiet, simpler ones) to creating useable organs in the lab. Nobody is going to invest heavily in R&D and wholesale manufacture of organs without a market in which to sell. Someday I will be able to buy an artificial organ grown in a lab from my own tissue, and it will happen a whole lot sooner if there is a mechanism in place to value and trade them.

You don't need to create a market in donated organs in order to create a market in lab-grown organs. The two are not mutually dependent nor mutually exclusive, they are separate markets. In fact, there are reserchers working on lab-grown organs right now, and I guarranty that if it were medically feasible to do today, there would be an immediate and BOOMING market for such organs. I also guarranty that there would be patent issues at stake, which would give the lucky company a monopoly on the procedure for years, and allow them to extract monopoly rents from it. The market value for lab-grown organs won't be set by the existing donated organs, any more than the price of a Rolls Royce is set by the price for a Corolla.

Thanks for this discussion. I've often wondered why it's unethical to pay a donor for an organ, but ethical for all the other people in the organ-transplant process to get paid. I think it's another example of rampant nanny-statism. Poor donors don't need to be nannied. They should have the freedom to sell their body parts if they want to.

How about a system where the people who were registered organ donors (say at least a year prior to their organ failure) get bumped up the waiting list? This seems to avoid the political problems of selling an opt-out system to the public, while relying on the principle of reciprocity as an advantage --- You get an organ faster because a priori you expressed a preference to give your organs up. This other person _chose_ not to volunteer their organs after death. They get lower priority because if we universalized their preference, they would not get an organ at all.

Rather than pay up front for organs, why not treat the donor like a spouse for Medicare and Social Security?

Opt-out makes me uneasy:

You have no right to your organs after you die because you don't need them anymore. But you don't need some of them before you die, either. Why should those greedy young punks hoard all the organs for themselves?

Does LifeSharers require that you agree to donate before you get your diagnosis? "Umm, yeah, you see, I was just sitting down to fill out the donor registration card when my doctor called me with the bad news. So, er, where's that kidney you promised?"